January 1, 2014 Volume 78, Number 1
SEE Question

Based on a recent study involving high-risk patients undergoing major noncardiac surgery, when comparing maintenance of anesthesia with sevoflurane to that with propofol, which of the following is MOST likely true?


(A) There was no difference between the groups in all-cause mortality.

(B) Patients who received sevoflurane had a lower risk of postoperative myocardial ischemia.

(C) Patients who received propofol had a higher occurrence of postoperative delirium.

(D) A higher degree of patient satisfaction was reported by patients who received propofol.


Perioperative myocardial ischemia after noncardiac surgery is a serious and relatively common complication. In patients with coronary artery disease, troponin release may occur in approximately eight percent of patients undergoing surgery and anesthesia while myocardial infarction may occur in approximately five percent of patients. Based on data from continuous electrocardiogram monitoring, myocardial ischemia may occur in up to 45 percent of these patients.


The American Heart Association has recommended the use of volatile anesthetics in patients with cardiovascular risk undergoing noncardiac surgery. Volatile agents such as sevoflurane, desflurane, and isoflurane have been noted to provide ischemic preconditioning against myocardial injury, especially in animal models. The authors of a recent study compared the effects of sevoflurane to those of propofol on perioperative risk of myocardial injury in patients with cardiovascular risk or disease undergoing major noncardiac surgery.


In this trial, patients were induced with etomidate, and anesthesia was maintained with either sevoflurane or propofol. The patients were then monitored for postoperative ischemia. Ischemia was detected by ST-segment abnormalities on continuous electrocardiogram or by troponin elevation. Other end points measured were postoperative Q-wave development, prohormone of brain natriuretic peptide release, and any major adverse cardiac events.


Overall, there was a 40 percent prevalence of perioperative ischemia observed among the patients in this trial. This high prevalence occurred in spite of perioperative administration of beta blockers, statins, and aspirin in most patients. The authors found that maintenance of anesthesia with sevoflurane rather than propofol did not reduce the risk of postoperative myocardial ischemia in high-risk patients undergoing major noncardiac surgery. No difference was observed between the groups in the occurrence of postoperative nausea and vomiting, perioperative delirium, patient satisfaction, or all-cause mortality. Under the conditions of this study, the use of a preconditioning agent (sevoflurane) provided no benefit on morbidity or mortality.


Answer: A

Interested in becoming a question writer for the SEE Program? Active ASA members are encouraged to submit their CVs for consideration to Regina Fragneto, M.D., SEE Editor-in-Chief, at fragnet@email.uky.edu.


The Self-Education and Evaluation (SEE) Program is a self-study CME program that highlights “emerging knowledge” in the field of anesthesiology.The program presents relevant topics from more than 40 of today’s leading international medical journals in an engaging question-discussion format. SEE can be used to help fulfill the CME requirements of MOCA®. To learn more and to subscribe, visit see.asahq.org.


• Lurati Buse GA, Schumacher P, Seeberger E, et al. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Circulation. 2012;126(23):2696-2704.

• Tanaka K, Ludwig LM, Kersten JR, Pagel PS, Warltier DC. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology. 2004;100(3):707-721.

• Chang TS, Fox JA. Coronary artery bypass grafting utilizing cardiopulmonary bypass. In: Vacanti CA, Sikka PK, Urman RD, Dershwitz M, Segal BS, eds. Essential Clinical Anesthesia. New York, NY: Cambridge University Press; 2011:453-460.